Very interesting proposals, most of which are well known ideas toward a better functioning system. Yet, there is something missing that continues to be an impediment toward that goal. It is the assumption that there exists an all knowing, benevolent, and unbiased entity that can " regulate" this system into existence. Perhaps cynically, the thought that two politicians diametrically opposed on almost everything somehow agree on a solution here should send chills down your spine. Asking government to set a level playing field is doomed to continue down the path of solutions resulting in more lobbying money, campaign contributions, price manipulation, and theatrically produced hearings bashing executives who continue raking in exorbitant pay packages. All in the name of affordable, high quality medical care. Face it, the thousands of small hospital administrators with exorbitant pay packages is also a problem, yet they just don't generate the eyeballs for TV ratings.
In the end, any solution that involves encouraging more government intervention and regulation, while removing the individual from having responsibility to pay the person providing the care directly will only result in abuse and corruption and a scattered multi-tiered system.
You want a regulation that will go far in straightening out incentives for all? Stop payments from insurance companies to hospitals and physicians and medical supply companies and pharmacies directly. Force these insurance companies to pay the people who are covered by these policies. Let the people see the outrageous abuse and costs along with the waste and let them write the check to these "providers" after receiving their insurance checks. Once the free market has a say in health care and it's value, the revolution toward an even playing field and true value will be discovered. But don't hold your breath waiting for it...
Thank you for your comments. To be clear, I'm not asking politicians to take on the task of ensuring an even playing field if what that means is they get to decide how integrated or big a healthcare corporation is. Rather, what I am suggesting is to repeal regulations that unfairly reward big healthcare corporations regardless of the value they provide to us, and to introduce reforms that make it easier for us as consumers to shape the market. In that sense, you are right that the proposals that I mention on their own are 'missing' something, namely, a reframing of the debate that it should be individuals, not politicians, deciding with their power as consumers and producers, how to shape the medical market.
We are talking apples and oranges. My experience is that doctor bills are crazy high, 80,000 for a hernia, your experience is you are not making the 300,000 a year you had expected. So is it the hospitals? Is it the medical schools? Insurance companies gouge us on the other side of the scalpel and refuse to pay you sufficiently. So where do we work together, I do not see we have shared interest monetarily. You need never ending surgeries for ailments that probably are self limiting or at least not truly necessary, we want unlimited services for regularly hypochondriac fantasies, and the hospitals and health giants pit us against each other. You give me the bill so I blame you.
This did not happen slowly. Healthcare has been taken over by a thousand cuts and will not change easily. IMHO the most significant destructive acts that have brought us here are.
1987/1993 Stark laws 1&2 because "Physicians are too greedy to control healthcare"
1997 direct to consumer drug marketing approved. (women's health initative classic example of how this law and subsequent direct to consumer, clickbait-ization of research, damage to women beyond comprehension)
2001 - "JCAH 5th vital sign. (say no more)
2010 - ACA/Obamacare making it only feasible to have health insurance if either you do not have nothing financially and you get Medicaid, or you have to work for large corporation.
2015 MACRA/MIPS causing the administrative Apocalypse that corporate medicine can navigate but small practice not so much.
2026 - now standardization of healthcare so docs cant make decisions but insurance, hosp corps and any Tom/Dick or Harry MBA can now tell a Doc he is not more knowledgeable than them, his MD means jack..... the Corp knows all........
The final kicker is if patients get hurt they dump on the doctors as responsible. Docs are the only ones in this system with personal, not corporate liability. Docs will always be the "fall guy"
I agree with most if not all of the above. I just do not think folks are organized enough to push for real, long lasting, meaningful change as it threatens the Medical Industrial Complex, and they control all the chips including our elected officials. As long as they help make politicians rich beyond any reasonable wealth accumulation possible just with their salary's, we will never see any change.
Nice attempt but the medical-legal-industrial complex is 5 steps ahead of you.
Only one solution. National health insurance paid from general tax revenues, or however they do it in Europe.
We don’t have capitalism in American healthcare. We have what Angus Deaton, No el laureate in economics calls “crony capitalism.”
Just pay the director general of the Canadian healthcare system five times what she’s getting paid now and have her bring her system south of the border. Get rid of the privates. They’re just parasites. Insurance is the cause of our problem not the solution. They’ve sold the song and dance too often to the American public that they are our friends. No, insurance is why things are so high. When insurance stopped paying for the GLP ones they became affordable. Get rid of health insurance, enroll everyone in Medicare. Let the national health system negotiate with the pharmaceutical companies. You’ll see their prices drop like a rock.
The director general of the Montreal General Hospital gets a lump sum money from the Canadian government January 1 and she has to make it work until December 31. There are no false incentives there. She has to take care of her given population to see that her employees are paid and then try and get to December 31. That’s accountability.
I’m an Eisenhower Republican, but have studied the European systems for 50 years and they work. And they work for people, not for plutocrats. And their physicians make decent salaries. And have a decent standard of living. I’ve received excellent care in Europe and my daughter lives in Austria and wants to stay there because our system doesn’t work for people. And her taxes aren’t any higher than mine! Yes, when you throw in 2 years of paid leave for each child born and your job guaranteed back and you get University of Vienna tuition for €800 a semester she pays less than I do. ( Big saving: they don’t have to kidnap foreign leaders, support genocide in Gaza, or rain down million dollar bombs on the desert.)
We have friends in European and South American countries that have national health care. These friends also buy personal health care insurance because there are advantages for them to have the extra health insurance.
I am okay with a national, basic plan, but I believe there is still a place for personal health care insurance for those that want and can afford it. Not to mention, it might take the pressure off the national plan.
As far as a national health care system being better, I've heard people who love it, and others who don't. I suppose it depends on how long they have to wait for their procedures. There are Canadians that come to the US to get care because the wait times are so long.
No system is perfect, but maybe a hybrid system might work better.
I agree with many of these suggestions re: incentive changes. As per usual, the government has tried to manipulate behavior of health care professionals and health care systems and we create meaningless busy work that just slows the entire process. I agree with CON changes, facility fee changes, 340b changes, etc. The entire "quality metrics" industry needs to disappear.
By simply making paperwork and processes more streamlined, we could reduce costs drastically without making huge changes otherwise. AI should be able to help with this. Hunkering down into HIPAA only slows things further. If we all don't recognize our information is "out there", we should. Extreme (and somewhat meaningless) "privacy" regulations are hinderances. To help make some of these changes at CMS level, we need collaboration and feed back from actual practicing physicians (ones that have been practicing for 25+ years and have experienced it all) rather than academic bureaucrats guiding structures.
Besides the monetary, reimbursement, payment side of things, we really need to revolutionize HOW we dispense medical care! Expand the health care 'system' - bring nutritionists and dietitians in. Rather than use phyicians to focus on "root causes" - for which you do not need a medical degree or MD license!, use other supportive professionals. You can't expect the highly trained experts who are needed to do the surgeries, manage the heart attacks, prescribe complicated medications to pivot to things that can be done by someone else. And why are doctors needed to see every patient with knee pain, shoulder pain, back pain, etc - this does not require prescriptions, high-level thinking and input. Physical therapists, kinesiologists, etc - bring about a whole other sector that deals with that. Rather than say we have a "physician shortage", take non-physician things off the plate.
Find options, other than 1:1 office visits to dispense health care. Come up with something new. Moving at that inefficient pace is not helping anything.
And, finally, we need to develop an "extreme elder" care track that more reasonably and more effectively cares for our over 85 citizens. Throwing them into the churn and burn system that is our current hospital system is not working. Running as many tests as humanly possible, pumping them with medicines, then booting them out to manage alone at home is just not working. Hospital systems are overwhelmed and hospital care is really at a breaking point for (true) quality and outcomes. Health care also needs to be organized per city/local environment in a more coordinated fashion. Having 90 year olds see a cardiologist once a year while the 65 year olds with chest pain wait it out for an appointment is just not appropriate or a good use of resources. Rather than independent medical offices staying siloed, we need to coordinate and manage the health of our communities. All of these things need to happen. Just shifting our "payors", even doing "Medicare for All" is not enough to keep up with the ever increasing demand.
my sense is that nothing in these areas will change and the "system" will simply break. Americans don't like to "wait" for anything in health care. Shifting to a "wait" structure is also an inefficient "allocation" of resources. The oldest of the baby boom cohort is just hitting 82 years old. These next 15 years are going to be difficult. no matter what else we do.
"feed back from actual practicing physicians" what a concept!!
Here's a bit of feedback: routine preventative care should be done by PAs or equivalent per established guidelines (yes I know, we can argue about what should be done). Physician time should be used for higher value services.
Agree. We should more critically evaluate what issues we even use physicians for. Having physician "quality metric" on how many of their patients get flu shots or mammograms, etc doesn't make much sense. Leaving it up to doctor-patient interaction to make these recommendations. Why?
The article gets close to the fundamental problem with our "healthcare system", namely that we've got this idea that medical care, which of course involves goods and services provided by others, should be paid for, not by the individual himself, but by some third party to whom we give our money and who then pays our bills after taking out his portion and at the same time deciding under what circumstances and in what amount he will make payment. There are historical reasons over the past many decades why we've adopted this arrangement, but it makes no practical sense. We don't do it with any of our other important needs, such as food and shelter.
Of course, medical care, like food and shelter, is something of a basic need, although not quite so important to life and limb as the other two, but important enough that most of us would agree that, like food and shelter, those who are especially needy or unfortunate should have some significant level provided to them by the rest of us arranged through government or charity. Everyone else should pay his own way, including those over age 65 or in any other category.
The article makes the excellent point that insurance is a mechanism in which we pay a company for arranging to pool funds from many insured individuals to cover the risk of high-cost unexpected events which the majority hope to never experience. Using "insurance" as a means of paying for every item or service is a guaranteed formula for absurdly high cost and abuse such as are detailed in the article. It always mystifies me how this simple fact is so little appreciated by a public which otherwise uses insurance more or less appropriately. The anticipated infirmities of old age are a reason for individual planned saving just as we do for retirement rather than reliance on an excessively costly, inevitably inefficient and dysfunctional government program that falls into the same irrational category.
Leaving everything to the market, with real insurance as a backup, is complicated by the need, as mentioned, for societal involvement in some number of individuals, even including those with problems that stem from neglect or self-abuse. So various government mechanisms to incentivize responsibility or to penalize the opposite are necessary. This is where government should step in to tweak market forces and not otherwise. Some are advocated in the article. Incentives, such as tax policies, should apply directly to individuals rather than indirectly such as through employment arrangements that lead to uneven distribution as mentioned in the article.
These are the basic principles which would guide us back to rational medical care economics and delivery. How we get there from the nonsensical structure we have built up over the last 70 or so years is another matter. But we won’t get there without first understanding the problem and this article helps.
Yes. Structures that began in the 1960s when medicine was at its core a much less expensive proposition and people weren't living as long no longer makes sense. We need to find other incentivizing methods and coverage models.
This is a proposal by a rich man, for rich people. Let everyone save so they can spend their own money on health care? Are these the same people who are supposed to save for their own retirement, while not currently being able to afford housing and food? Right.
"There are no solutions. There are only tradeoffs". Thomas Sowell
What we have now and with any proposed changes, positive and negative effects. We have many bizarre and frustrating problems in our current "system" leading to anger and a reaching for any semi-attractive "solution" crossing our internet feed without regard for the down side.
A simple way to assess the downsides of your proposal is to honestly (rare these days) list an opponent's take, and the opponent to list the proposal's strength. We all know this is not being done.
You lost me in the details. I don't see the over all model of care that you are aiming for. I see no reason for the for-profit heatlhcare business, By definition that will increase costs because the profit, being not part of the cost of health care does nothing to contribute to lowering the cost of care, it adds to it. Non profit organizations get "profit" but they use that for the required capital costs to provide care. Shouldn't all money for healthcare go to healthcare?
You lost me at profits. Generally speaking, no, profits are not a surplus extracted from from some good. Profits can come many many things, but most often it comes from the effort and innovation from using capital to create new and better ways of providing value. In some cases then, profits can come from lowering costs, if one has identified waste and inefficiencies in how goods are being provided. In healthcare, profits right now seems to be made by both providing value (i.e., innovation) AND regulatory capture. What I would like to see is corporations focuses only on providing me value (and being able to walk away if they don't), not on regulatory capture to accumulate profit with no benefit to me.
Agree to disagree. "Profits are not a surplus extracted from some good." But they are an additional tax on the costs of those goods and services that is removed from the health care budget, and goes to shareholders and business owners, not to patient care. I worked at a nonprofit health organization and we were motivated and successful in decreasing costs and find best ways to provide value. Every penny that goes to "profit" in a nonprofit business is taken away from the potential operating budget diminishing the main goal of that business.
Lots of good suggestions here. Any effective solution will require the removal of government from the medical care market---no subsidies, tax breaks, or other regulations. Partial moves toward a free market system may be of some help here and there, but will eventually devolve back to the same types of problems we have now.
I don't see there ever being a time when government will not be involved in medical care because of the relatively critical nature of the need for it, even from the practical rather than the moral point of view. But backing off from the Medicare fiasco and tax policy that incentivizes all encompassing "health insurance" instead of salary I think is possible when things get bad enough to convince the public and the medical profession to make changes. Hopefully they won't be stupid enough to accept the "Medicare for all" fallacy.
I think partial moves can be sustained overtime with the right motivation and vision. Without the latter, yes, you are right, moves towards a free market will devolve back.
I don't reject the idea that partial moves can be beneficial but fundamental change at the institutional level is necessary to have a real chance at lasting reform e.g. eliminate all government "health" related entities. Too many think that just getting the right people in charge will bring about needed changes. Granted that an odious institution can be re-established but that is much more difficult than putting a new bureaucrat in charge.
I agree that fundamental change is necessary, but I think that the focus on eliminating all government 'health' related entities, as you say, is not how I would frame it or go about it. Yes, long term those need to go (except for legitimate public health functions like communicable disease and pandemic prevention). My focus would be on making the private sector truly private, which it isn't right now, since the public and private sectors bleed into one another (think of the outsized role of CMS on all of health insurance). That way, it's less about eliminating government entities as such, and more about creating space for a truly private sector so that they can respond to market signals, rather than responding to regulations and compliance set out by said government entities.
I like your article's recommendations, but it seems to me that advantage can be taken of the growing dissatisfaction on the part of the medical providers as well as the public with the present system. As an example, the growing movement of doctors to drop out needs to be encouraged to find ways to do it. And those who do drop out need to have a greater presence in their medical organizations. As a foot in the door they could work to reform Medicare to permit balance billing and private contracting just as government programs do in other advanced countries. This would allow Medicare more leeway in controlling fees and incentivize efforts toward privatization and perhaps even eventually a blending of Medicare and Medicaid into one program limited to needy individuals.
I understand and appreciate your positions. I just think that it is impossible to create space for a truly private sector as long as there are government agencies with coercive powers. They will simply reinstitute other forms of regulation using different labels and phrases. In my opinion, the public health agencies were the prime mover in this direction in the recent covid episode.
No, that is the problem as big medicine will always remain big and keep the nutty healthcare system fully intact. Blow the whole thing up as it becomes more useless by the day. I do not take part in any of it but my wife does and I have seen the destruction that BIG MEDICINE has done to her. I can tolerate none of you madmen.
The writer starts by acknowledging that"And what it reveals is an uneven playing field that rewards corporations for getting bigger through regulatory capture regardless of the value they provide" and then proceeds to argue that size is not a problem...
That's right. Size is not the problem, since size is just a reflection of what the system rewards. What the system rewards is the problem. Basically what I am saying that 'bigness' is not a helpful way to think about what ails the healthcare system, since bigness can also include things that are valuable and that some people might want. For example, I would very much like to be able to get my healthcare from a businesses where I can pick up my medication in the doctor's office (which is one kind of vertical integration). But what I don't want is for my employer to decide that for me, nor for the business that I interact with to be focused on regulatory capture instead of my needs.
Unfortunately many legislators think the solution is Medicare for all, the ultimate regulation. In California we have yet another bill pushing for the creation of CalCare where seniors sign their Medicare benefits over to a state that has demonstrated poor fiscal responsibility. No one gets that perhaps the ACA inadvertently or intentionally orchestrated this consolidation mess.
Yeah, all of those models will disenfranchise many people with chronic illnesses. Especially those who live with autoimmune disease or multiple autoimmune diseases (autoimmune clustering).
Very interesting proposals, most of which are well known ideas toward a better functioning system. Yet, there is something missing that continues to be an impediment toward that goal. It is the assumption that there exists an all knowing, benevolent, and unbiased entity that can " regulate" this system into existence. Perhaps cynically, the thought that two politicians diametrically opposed on almost everything somehow agree on a solution here should send chills down your spine. Asking government to set a level playing field is doomed to continue down the path of solutions resulting in more lobbying money, campaign contributions, price manipulation, and theatrically produced hearings bashing executives who continue raking in exorbitant pay packages. All in the name of affordable, high quality medical care. Face it, the thousands of small hospital administrators with exorbitant pay packages is also a problem, yet they just don't generate the eyeballs for TV ratings.
In the end, any solution that involves encouraging more government intervention and regulation, while removing the individual from having responsibility to pay the person providing the care directly will only result in abuse and corruption and a scattered multi-tiered system.
You want a regulation that will go far in straightening out incentives for all? Stop payments from insurance companies to hospitals and physicians and medical supply companies and pharmacies directly. Force these insurance companies to pay the people who are covered by these policies. Let the people see the outrageous abuse and costs along with the waste and let them write the check to these "providers" after receiving their insurance checks. Once the free market has a say in health care and it's value, the revolution toward an even playing field and true value will be discovered. But don't hold your breath waiting for it...
Thank you for your comments. To be clear, I'm not asking politicians to take on the task of ensuring an even playing field if what that means is they get to decide how integrated or big a healthcare corporation is. Rather, what I am suggesting is to repeal regulations that unfairly reward big healthcare corporations regardless of the value they provide to us, and to introduce reforms that make it easier for us as consumers to shape the market. In that sense, you are right that the proposals that I mention on their own are 'missing' something, namely, a reframing of the debate that it should be individuals, not politicians, deciding with their power as consumers and producers, how to shape the medical market.
We are talking apples and oranges. My experience is that doctor bills are crazy high, 80,000 for a hernia, your experience is you are not making the 300,000 a year you had expected. So is it the hospitals? Is it the medical schools? Insurance companies gouge us on the other side of the scalpel and refuse to pay you sufficiently. So where do we work together, I do not see we have shared interest monetarily. You need never ending surgeries for ailments that probably are self limiting or at least not truly necessary, we want unlimited services for regularly hypochondriac fantasies, and the hospitals and health giants pit us against each other. You give me the bill so I blame you.
This did not happen slowly. Healthcare has been taken over by a thousand cuts and will not change easily. IMHO the most significant destructive acts that have brought us here are.
1987/1993 Stark laws 1&2 because "Physicians are too greedy to control healthcare"
1997 direct to consumer drug marketing approved. (women's health initative classic example of how this law and subsequent direct to consumer, clickbait-ization of research, damage to women beyond comprehension)
2001 - "JCAH 5th vital sign. (say no more)
2010 - ACA/Obamacare making it only feasible to have health insurance if either you do not have nothing financially and you get Medicaid, or you have to work for large corporation.
2015 MACRA/MIPS causing the administrative Apocalypse that corporate medicine can navigate but small practice not so much.
2026 - now standardization of healthcare so docs cant make decisions but insurance, hosp corps and any Tom/Dick or Harry MBA can now tell a Doc he is not more knowledgeable than them, his MD means jack..... the Corp knows all........
The final kicker is if patients get hurt they dump on the doctors as responsible. Docs are the only ones in this system with personal, not corporate liability. Docs will always be the "fall guy"
I agree with most if not all of the above. I just do not think folks are organized enough to push for real, long lasting, meaningful change as it threatens the Medical Industrial Complex, and they control all the chips including our elected officials. As long as they help make politicians rich beyond any reasonable wealth accumulation possible just with their salary's, we will never see any change.
Nice attempt but the medical-legal-industrial complex is 5 steps ahead of you.
Only one solution. National health insurance paid from general tax revenues, or however they do it in Europe.
We don’t have capitalism in American healthcare. We have what Angus Deaton, No el laureate in economics calls “crony capitalism.”
Just pay the director general of the Canadian healthcare system five times what she’s getting paid now and have her bring her system south of the border. Get rid of the privates. They’re just parasites. Insurance is the cause of our problem not the solution. They’ve sold the song and dance too often to the American public that they are our friends. No, insurance is why things are so high. When insurance stopped paying for the GLP ones they became affordable. Get rid of health insurance, enroll everyone in Medicare. Let the national health system negotiate with the pharmaceutical companies. You’ll see their prices drop like a rock.
The director general of the Montreal General Hospital gets a lump sum money from the Canadian government January 1 and she has to make it work until December 31. There are no false incentives there. She has to take care of her given population to see that her employees are paid and then try and get to December 31. That’s accountability.
I’m an Eisenhower Republican, but have studied the European systems for 50 years and they work. And they work for people, not for plutocrats. And their physicians make decent salaries. And have a decent standard of living. I’ve received excellent care in Europe and my daughter lives in Austria and wants to stay there because our system doesn’t work for people. And her taxes aren’t any higher than mine! Yes, when you throw in 2 years of paid leave for each child born and your job guaranteed back and you get University of Vienna tuition for €800 a semester she pays less than I do. ( Big saving: they don’t have to kidnap foreign leaders, support genocide in Gaza, or rain down million dollar bombs on the desert.)
We have friends in European and South American countries that have national health care. These friends also buy personal health care insurance because there are advantages for them to have the extra health insurance.
I am okay with a national, basic plan, but I believe there is still a place for personal health care insurance for those that want and can afford it. Not to mention, it might take the pressure off the national plan.
As far as a national health care system being better, I've heard people who love it, and others who don't. I suppose it depends on how long they have to wait for their procedures. There are Canadians that come to the US to get care because the wait times are so long.
No system is perfect, but maybe a hybrid system might work better.
I agree with many of these suggestions re: incentive changes. As per usual, the government has tried to manipulate behavior of health care professionals and health care systems and we create meaningless busy work that just slows the entire process. I agree with CON changes, facility fee changes, 340b changes, etc. The entire "quality metrics" industry needs to disappear.
By simply making paperwork and processes more streamlined, we could reduce costs drastically without making huge changes otherwise. AI should be able to help with this. Hunkering down into HIPAA only slows things further. If we all don't recognize our information is "out there", we should. Extreme (and somewhat meaningless) "privacy" regulations are hinderances. To help make some of these changes at CMS level, we need collaboration and feed back from actual practicing physicians (ones that have been practicing for 25+ years and have experienced it all) rather than academic bureaucrats guiding structures.
Besides the monetary, reimbursement, payment side of things, we really need to revolutionize HOW we dispense medical care! Expand the health care 'system' - bring nutritionists and dietitians in. Rather than use phyicians to focus on "root causes" - for which you do not need a medical degree or MD license!, use other supportive professionals. You can't expect the highly trained experts who are needed to do the surgeries, manage the heart attacks, prescribe complicated medications to pivot to things that can be done by someone else. And why are doctors needed to see every patient with knee pain, shoulder pain, back pain, etc - this does not require prescriptions, high-level thinking and input. Physical therapists, kinesiologists, etc - bring about a whole other sector that deals with that. Rather than say we have a "physician shortage", take non-physician things off the plate.
Find options, other than 1:1 office visits to dispense health care. Come up with something new. Moving at that inefficient pace is not helping anything.
And, finally, we need to develop an "extreme elder" care track that more reasonably and more effectively cares for our over 85 citizens. Throwing them into the churn and burn system that is our current hospital system is not working. Running as many tests as humanly possible, pumping them with medicines, then booting them out to manage alone at home is just not working. Hospital systems are overwhelmed and hospital care is really at a breaking point for (true) quality and outcomes. Health care also needs to be organized per city/local environment in a more coordinated fashion. Having 90 year olds see a cardiologist once a year while the 65 year olds with chest pain wait it out for an appointment is just not appropriate or a good use of resources. Rather than independent medical offices staying siloed, we need to coordinate and manage the health of our communities. All of these things need to happen. Just shifting our "payors", even doing "Medicare for All" is not enough to keep up with the ever increasing demand.
my sense is that nothing in these areas will change and the "system" will simply break. Americans don't like to "wait" for anything in health care. Shifting to a "wait" structure is also an inefficient "allocation" of resources. The oldest of the baby boom cohort is just hitting 82 years old. These next 15 years are going to be difficult. no matter what else we do.
"feed back from actual practicing physicians" what a concept!!
Here's a bit of feedback: routine preventative care should be done by PAs or equivalent per established guidelines (yes I know, we can argue about what should be done). Physician time should be used for higher value services.
Agree. We should more critically evaluate what issues we even use physicians for. Having physician "quality metric" on how many of their patients get flu shots or mammograms, etc doesn't make much sense. Leaving it up to doctor-patient interaction to make these recommendations. Why?
The article gets close to the fundamental problem with our "healthcare system", namely that we've got this idea that medical care, which of course involves goods and services provided by others, should be paid for, not by the individual himself, but by some third party to whom we give our money and who then pays our bills after taking out his portion and at the same time deciding under what circumstances and in what amount he will make payment. There are historical reasons over the past many decades why we've adopted this arrangement, but it makes no practical sense. We don't do it with any of our other important needs, such as food and shelter.
Of course, medical care, like food and shelter, is something of a basic need, although not quite so important to life and limb as the other two, but important enough that most of us would agree that, like food and shelter, those who are especially needy or unfortunate should have some significant level provided to them by the rest of us arranged through government or charity. Everyone else should pay his own way, including those over age 65 or in any other category.
The article makes the excellent point that insurance is a mechanism in which we pay a company for arranging to pool funds from many insured individuals to cover the risk of high-cost unexpected events which the majority hope to never experience. Using "insurance" as a means of paying for every item or service is a guaranteed formula for absurdly high cost and abuse such as are detailed in the article. It always mystifies me how this simple fact is so little appreciated by a public which otherwise uses insurance more or less appropriately. The anticipated infirmities of old age are a reason for individual planned saving just as we do for retirement rather than reliance on an excessively costly, inevitably inefficient and dysfunctional government program that falls into the same irrational category.
Leaving everything to the market, with real insurance as a backup, is complicated by the need, as mentioned, for societal involvement in some number of individuals, even including those with problems that stem from neglect or self-abuse. So various government mechanisms to incentivize responsibility or to penalize the opposite are necessary. This is where government should step in to tweak market forces and not otherwise. Some are advocated in the article. Incentives, such as tax policies, should apply directly to individuals rather than indirectly such as through employment arrangements that lead to uneven distribution as mentioned in the article.
These are the basic principles which would guide us back to rational medical care economics and delivery. How we get there from the nonsensical structure we have built up over the last 70 or so years is another matter. But we won’t get there without first understanding the problem and this article helps.
Yes. Structures that began in the 1960s when medicine was at its core a much less expensive proposition and people weren't living as long no longer makes sense. We need to find other incentivizing methods and coverage models.
This is a proposal by a rich man, for rich people. Let everyone save so they can spend their own money on health care? Are these the same people who are supposed to save for their own retirement, while not currently being able to afford housing and food? Right.
"There are no solutions. There are only tradeoffs". Thomas Sowell
What we have now and with any proposed changes, positive and negative effects. We have many bizarre and frustrating problems in our current "system" leading to anger and a reaching for any semi-attractive "solution" crossing our internet feed without regard for the down side.
A simple way to assess the downsides of your proposal is to honestly (rare these days) list an opponent's take, and the opponent to list the proposal's strength. We all know this is not being done.
IF we adopt these suggestions next answer these questions:
1.what happens when a patient does not pay for their bills from a service providers and or insurers?
2. what happens when they do not purchase catastrophic insurance and present with a high-cost medical event?
do we deny care?
You lost me in the details. I don't see the over all model of care that you are aiming for. I see no reason for the for-profit heatlhcare business, By definition that will increase costs because the profit, being not part of the cost of health care does nothing to contribute to lowering the cost of care, it adds to it. Non profit organizations get "profit" but they use that for the required capital costs to provide care. Shouldn't all money for healthcare go to healthcare?
You lost me at profits. Generally speaking, no, profits are not a surplus extracted from from some good. Profits can come many many things, but most often it comes from the effort and innovation from using capital to create new and better ways of providing value. In some cases then, profits can come from lowering costs, if one has identified waste and inefficiencies in how goods are being provided. In healthcare, profits right now seems to be made by both providing value (i.e., innovation) AND regulatory capture. What I would like to see is corporations focuses only on providing me value (and being able to walk away if they don't), not on regulatory capture to accumulate profit with no benefit to me.
Agree to disagree. "Profits are not a surplus extracted from some good." But they are an additional tax on the costs of those goods and services that is removed from the health care budget, and goes to shareholders and business owners, not to patient care. I worked at a nonprofit health organization and we were motivated and successful in decreasing costs and find best ways to provide value. Every penny that goes to "profit" in a nonprofit business is taken away from the potential operating budget diminishing the main goal of that business.
Lots of good suggestions here. Any effective solution will require the removal of government from the medical care market---no subsidies, tax breaks, or other regulations. Partial moves toward a free market system may be of some help here and there, but will eventually devolve back to the same types of problems we have now.
I don't see there ever being a time when government will not be involved in medical care because of the relatively critical nature of the need for it, even from the practical rather than the moral point of view. But backing off from the Medicare fiasco and tax policy that incentivizes all encompassing "health insurance" instead of salary I think is possible when things get bad enough to convince the public and the medical profession to make changes. Hopefully they won't be stupid enough to accept the "Medicare for all" fallacy.
I think partial moves can be sustained overtime with the right motivation and vision. Without the latter, yes, you are right, moves towards a free market will devolve back.
I don't reject the idea that partial moves can be beneficial but fundamental change at the institutional level is necessary to have a real chance at lasting reform e.g. eliminate all government "health" related entities. Too many think that just getting the right people in charge will bring about needed changes. Granted that an odious institution can be re-established but that is much more difficult than putting a new bureaucrat in charge.
I agree that fundamental change is necessary, but I think that the focus on eliminating all government 'health' related entities, as you say, is not how I would frame it or go about it. Yes, long term those need to go (except for legitimate public health functions like communicable disease and pandemic prevention). My focus would be on making the private sector truly private, which it isn't right now, since the public and private sectors bleed into one another (think of the outsized role of CMS on all of health insurance). That way, it's less about eliminating government entities as such, and more about creating space for a truly private sector so that they can respond to market signals, rather than responding to regulations and compliance set out by said government entities.
I like your article's recommendations, but it seems to me that advantage can be taken of the growing dissatisfaction on the part of the medical providers as well as the public with the present system. As an example, the growing movement of doctors to drop out needs to be encouraged to find ways to do it. And those who do drop out need to have a greater presence in their medical organizations. As a foot in the door they could work to reform Medicare to permit balance billing and private contracting just as government programs do in other advanced countries. This would allow Medicare more leeway in controlling fees and incentivize efforts toward privatization and perhaps even eventually a blending of Medicare and Medicaid into one program limited to needy individuals.
I understand and appreciate your positions. I just think that it is impossible to create space for a truly private sector as long as there are government agencies with coercive powers. They will simply reinstitute other forms of regulation using different labels and phrases. In my opinion, the public health agencies were the prime mover in this direction in the recent covid episode.
No, that is the problem as big medicine will always remain big and keep the nutty healthcare system fully intact. Blow the whole thing up as it becomes more useless by the day. I do not take part in any of it but my wife does and I have seen the destruction that BIG MEDICINE has done to her. I can tolerate none of you madmen.
The writer starts by acknowledging that"And what it reveals is an uneven playing field that rewards corporations for getting bigger through regulatory capture regardless of the value they provide" and then proceeds to argue that size is not a problem...
That's right. Size is not the problem, since size is just a reflection of what the system rewards. What the system rewards is the problem. Basically what I am saying that 'bigness' is not a helpful way to think about what ails the healthcare system, since bigness can also include things that are valuable and that some people might want. For example, I would very much like to be able to get my healthcare from a businesses where I can pick up my medication in the doctor's office (which is one kind of vertical integration). But what I don't want is for my employer to decide that for me, nor for the business that I interact with to be focused on regulatory capture instead of my needs.
Unfortunately many legislators think the solution is Medicare for all, the ultimate regulation. In California we have yet another bill pushing for the creation of CalCare where seniors sign their Medicare benefits over to a state that has demonstrated poor fiscal responsibility. No one gets that perhaps the ACA inadvertently or intentionally orchestrated this consolidation mess.
Yeah, all of those models will disenfranchise many people with chronic illnesses. Especially those who live with autoimmune disease or multiple autoimmune diseases (autoimmune clustering).